It is hard to see how the present manuscript could have reached completion without the understanding and energy contributed to its making by my secretary, Miss Julia Littlejohn.
Mr. Berry Fleming and Mr. Donald Parson, one as a distinguished novelist and one as a poet, but both sharing the psychiatrist’s interest in human personality, have kindly made available to me their valuable points of view.
This volume owes a large debt to Dr. W. R. Houston, formerly Clinical Professor of Medicine in the University of Georgia School of Medicine, now of Austin, Texas. As my first teacher in psychiatry and still as a bracingly honest critic and a skeptical but always heartening guide, Dr. Houston’s uncommon learning in many fields and his kindness have been an important support.
Most of all it is my pleasure to thank Dr. V. P. Sydenstricker, Professor of Medicine in the University of Georgia School of Medicine, whose genuine human qualities no less than his specific achievements in medicine and his remarkable energy, have encouraged, year after year, scores of less seasoned and sometimes groping colleagues to do sounder work and to find joy that is the stuff of life in even those daily tasks that would in another’s presence become mere routine. Real wisdom joined with real humor cannot fail to be expressed in a rare and discerning kindness. These qualities, all in full measure, have done more not only to deal with illness, but also to reintegrate at happier and more effective levels those who have worked with him than their possessor can realize. It is indeed difficult to express fairly the gratitude which informs this writer in mentioning the constant encouragement, generous help, and the major inspiration that have come from Dr. Sydenstricker to the Department of Neuropsychiatry.
Hervey Cleckley
Augusta, Georgia, 1941
Section One: An Outline of the Problem
Sanity — A Protean Concept
A millionaire notable for his eccentricity had an older and better balanced brother who, on numerous fitting occasions, exercised strong persuasion to bring him under psychiatric care. On receiving word that this wiser brother had been deserted immediately after the nuptial night by a famous lady of the theatre (on whom he had just settled a large fortune) and that the bride, furthermore, had, during the brief pseudoconnubial episode, remained stubbornly encased in tights, the younger hastened to dispatch this succinct and unanswerable telegram:
WHO’S LOONEY NOW?
This, at any rate, is the story. I do not offer to answer for its authenticity. It may, however, be taken not precisely as an example but at least as a somewhat flippant and arresting commentary on the confusion which still exists concerning sanity. Although most patients suffering from one of the classified types of mental disorder are promptly recognized by the psychiatrist, many of them being even to the layman plainly deranged, there remains a large body of people who, everyone will admit, are by no means adapted for normal life in the community and who, yet, have no official standing in the ranks of the insane. The word insane, of course, is not a medical term. It is employed here because to many people it conveys a more practical meaning than the medical term psychotic. Although the medical term with its greater vagueness presents a fairer idea of the present conception of severe mental disorder, the legal term better implies the criteria by which the personalities under discussion are judged in the courts.
Many of these people, legally judged as competent, are more dangerous to themselves and to others than are some patients whose psychiatric disability will necessitate their spending their entire lives in the state hospital. Though certified automatically as sane by the verbal definitions of law and of medicine, their behavior demonstrates an irrationality and incompetence that are gross and obvious.
1. Material to Distinguish from Our Subject
These people to whom I mean to call specific attention are not the borderline cases in whom the characteristics of some familiar mental disorder are only partially developed and the picture as a whole is still questionable. Many such cases exist, of course, and they are sometimes puzzling even to the experienced psychiatrist. Certain people, as everyone knows, may for many years show to a certain degree the reactions of schizophrenia (dementia praecox) of manic-depressive psychosis, or a paranoia without being sufficiently disabled or so generally irrational as to be recognized as psychotic. Many patients suffering from incipient disorders of this sort or from dementia paralytica, cerebral arteriosclerosis, and other organic conditions pass through a preliminary phase during which their thought and behavior are to a certain degree characteristic of the psychosis, while for the time being they remain able to function satisfactorily in the community.
Some people in the early stage of these familiar clinical disorders behave, on the whole, with what is regarded as mental competency, while showing, from time to time, symptoms typical of the psychosis toward which they are progressing. After the disability has at last become openly manifest, enough episodes of deviated conduct can often be noted in retrospect to make the observer wonder why the subject was not long ago recognized as psychotic. It would, however, sometimes be not only difficult but unfair to pronounce a person totally disabled while most of his conduct remains acceptable. Do we not, as a matter of fact, have to admit that all of us behave at times with something short of complete rationality and good judgment?
* * *
I recall a highly respected businessman who, after years of outstanding commercial success, began to send telegrams to the White House ordering the President to dispatch the Atlantic Fleet to Madagascar and to execute Roman Catholics. There was at this time no question, of course, about his disability. A careful study revealed that for several years he had occasionally made fantastic statements, displayed extraordinary behavior (for instance, once putting the lighted end of a cigar to his stenographer’s neck by way of greeting), and squandered thousands of dollars buying up stamp collections, worthless atticfuls of old furniture, and sets of encyclopedias by the dozen. None of these purchases had he put to any particular use. When finally discovered to be incompetent from illness, an investigation of his status showed that he had thrown away the better part of a million dollars. For months he had been maintaining 138 bird dogs scattered over the countryside, forty-two horses, and fourteen women, to none of whom he resorted for the several types of pleasure in which such dependents sometimes play a part.
Aside from persons in the early stages of progressive illness, one finds throughout the nation, and probably over the world, a horde of citizens who stoutly maintain beliefs regarded as absurd and contrary to fact by society as a whole. Often these people indulge in conduct that to others seems unquestionably irrational.
For example, the daily newspapers continue to report current gatherings in many states where hundreds of people handle poisonous snakes, earnestly insisting that they are carrying out God’s will.* Death from snakebite among these zealous worshippers does not apparently dampen their ardor. Small children, too young to arrive spontaneously at similar conclusions concerning the relationships between faith and venom, are not spared by their parents this intimate contact with the rattler and the copperhead.
It is, perhaps, not remarkable that prophets continually predict the end of the world, giving precise and authoritative details of what so far has proved no less fanciful than the delusions of patients confined in psychiatric hospitals. That scores and sometimes hundred or even thousands of followers accept these prophecies might give the thoughtful more cause to wonder. Newspaper clippings and magazine articles before the writer at this moment describe numerous examples of such behavior.
In a small Georgia town twenty earnest disciples sit up with a pious lady who has convinced them that midnight will bring the millennium. An elderly clergyman in California, whose more numerous followers are likewise disappointed when the designated moment passes uneventfully, explains that there is no fault with his divine vision but only some minor error of calculation which arose from differences between the Biblical and the modern calendars. During the last century an even
more vehement leader had thousands of people, in New England and in other states, out on the hillsides expecting to be caught up to glory as dawn broke. Indeed, conviction was so great that at sunrise many leaped from cliffs, roofs, and silos, one zealot having tied turkey wings to his arms the better to provide for flight. Those who had hoped to ascend found gravity unchanged, the earth still solid, and the inevitable contact jarring.268,283
Few, if any, who prophesy on the grounds of mystic insight or special revelation come to conclusions more extraordinary than those reached by some who profess, and often firmly believe, they are working within the methods of science. A notable example is furnished by Wilhelm Reich, who is listed in American Men of Science and whose earlier work in psychopathology is regarded by many as valuable.28 Textbooks of high scientific standing still refer to his discoveries in this field.79,129,188
It is indeed startling when such a person as this announces the discovery of “orgone,” a substance which, it is claimed, has much to do with sexual orgasm (as well as the blueness of the sky) and which can be accumulated in boxes lined with metal.
Those who sit within the boxes are said to benefit in many marvelous ways. According to the Journal of the American Medical Association, the accumulation of this (to others) nonexistent material is by Reich and his followers promoted as a method for curing cancer.59 A report of the Council of the American Medical Association lists the orgone accumulator with various quack nostrums under “Frauds and Fables.” The presence of any such material as “orgone” impresses the physician as no less imaginary than its alleged therapeutic effects. The nature of such conclusions and the methods of arriving at them are scarcely more astonishing than the credulity of highly educated and intellectual people who are reported to give them earnest consideration.28
During the 1940s, crowds estimated as containing twenty-five thousand or more persons, some of them having travelled halfway across the United States, stood in the rain night after night to watch a 9-year-old boy in New York City who claimed to have seen a vision which he described as “an angel’s head with butterfly wings.”
A clergyman of the Church of England during World War II confirmed as a supernatural omen of good the reported appearance of a luminous cross in the sky near Ipswich. In our own generation men of profound learning have expressed literal belief in witchcraft and approved the efforts of those who, following the Biblical injunction, put thousands to death for this activity.300
These headlines from a daily newspaper deserve consideration:
NOW IN MENTAL HOSPITAL, ACCUSED OF TREASON, HELD INSANE, EZRA POUND GIVEN TOP POETRY PRIZE
My interest in this news does not indicate that I hold it to be impossible for a person with a serious psychiatric disorder sometimes to write good poetry or to achieve other worthwhile attainments.
The headlines nevertheless reflect a bewildering conflict of evaluation in which some of the paradoxical elements strongly suggest absurdity. They also bring to mind what sometimes seems to be a rapt predilection of small but influential cults of intellectuals or esthetes for what is generally regarded as perverse, dispirited, or distastefully unintelligible.5,36,114, 253 The award of a Nobel Prize in literature to André Gide, who in his work fervently and openly insists that pederasty is the superior and preferable way of life for adolescent boys, furnishes a memorable example of such judgments.94,198 Renowned critics and some professors in our best universities179,282 reverently acclaim as the superlative expression of genius James Joyce’s Finnegan’s Wake, a 628-page collection of erudite gibberish indistinguishable to most people from the familiar word salad produced by hebephrenic patients on the back wards of any state hospital.
Let us illustrate briefly with the initial page from this remarkable volume:154
Riverrun, past Eve and Adam’s, from swerve of shore to bend of bay, brings us by a commodius vicus of recirculation back to Howth Castle and Environs.
Sir Tristram, violer d’amores, fr’over the short sea, had passencore rearrived from North Armorica on this side the scraggy isthmus of Europe Minor to wielderfight his penisolate war: nor had topsawyer’s rocks by the stream Oconee exaggerated themselse to Laurens County’s gorgios while they went doublin their mumper all the time: nor avoice from afire bellowsed mishe mishe to tauftauf thuartpeatrick: not yet, though venissoon after, had a kidscad buttened a bland old isaac: not yet, though all’s fair in vanessy, were sosie sesthers wroth with twone nathandjoe. Rot a peck of pa’s malt had Jhem or Shen brewed by arclight and rory end to the regginbrow was to be seen ringsome on the aquaface.
The fall bababadalgharaghtakamminarronnkonnbronntonnerronntuonnthunntrovarrhoun awnskawntoohoohoordenenthurnukl) of a once wallstrait oldparr is retaled early in bed and later on life down through all christian minstrelsy. The great fall of the offwall entailed at such short notice the pftjschute of Finnegan, erse solid man, that the humptyhillhead of humself prumptly sends an unquiring one well to the west in quest of his tumptytumtoes: and their upturnpikepointandplace is at the knock out in the park where oranges have been laid to rust upon the green since devlinsfirst loved livvy.
The adventurous reader will, I promise, find any of the other 627 pages equally illuminating. It is not for me to say dogmatically that Finnegan’s Wake is a volume devoid of meaning. Nor could I with certainty make such a pronouncement about the chaotic verbal productions of the patient on the back ward of an old time state hospital.
Ezra Pound’s continued eminence as a poet and the almost worshipful admiration with which some scholars acclaim Finnegan’s Wake are likely to evoke wonder from the man of ordinary tastes and reactions if he gives these matters serious consideration.
Graduates of our universities and successful businessmen join others to contribute testimonials announcing the prevention of hydrophobia and the healing of cancer, diphtheria, tuberculosis, wens, and broken legs, as well as the renting of rooms and the raising of salaries, by groups who reportedly work through “the formless, omnipresent God-substance” and by other metaphysical methods. One group publishes several magazines which are eagerly read in almost every town in the United States. Nearly two hundred centers are listed where “prosperity bank drills” and respiratory rituals are advocated. Leaders solemnly write, “the physical body radiates an energy that can at times be seen as a light or aura surrounding the physical, especially about the heads of those who think much about Spirit.”81
The following are typical testimonial letters, and these are but three among many hundreds:286
I wrote to you somewhat over a week ago asking for your prayers. My trouble was appendicitis, and it seemed that an operation was unavoidable. However, I had faith in the indwelling, healing Christ and decided to get in touch with you. Well, as you might expect, the healing that has taken place borders on the so-called miraculous. I spent an hour each day alone with God, and I claimed my rightful inheritance as a child of God. Naturally the adverse condition had to disappear with the advent of the powerful flow of Christ-Life consciously directed towards this illness.
* * *
You will be interested to know that just about the time when my prosperity-bank period was up I went to work in a new position, which not only pays a substantially higher salary but … [etc.]. I should probably not have had sufficient faith and courage to trust Him had it not been for the Truth literature.
* * *
Thank you for your beautiful and effective ministry. I have had five big demonstrations of prosperity since I had this particular prosperity bank. Last week brought final settlement of a debt owed me for about seven years.
Not a few citizens of our country read, apparently with conviction, material such as that published by the director of the Institute of Mental Physics, who is announced as the reincarnation of a Tibetan Lama. This leader reports, furthermore, that he has witnessed an eastern sage grow an orange tree from his palm and, on another occasion, die and rise in a new body, leaving the old one behind. Many other equally improbable feats of t
haumaturgy are described in eye-witness accounts.70
The casual observer has been known to dismiss what many call superstition as the fruit of ignorance. Nevertheless, beliefs and practices of this sort are far from rare among the most learned in all generations. A fairly recent ambassador to the United States, generally recognized as a distinguished scholar, died (according to the press) under the care of a practitioner of Christian Science.
Even a doctor of medicine has written a book in which he attests to the cure of acute inflammatory diseases and other disorders by similar methods. But let him speak directly:264
At another time I examined a girl upon whom I had operated for recurrent mastoiditis. At the time of my examination she was showing definite signs of another attack. … Absent treatments stopped her trouble in two days. To one who had never seen anything of the kind before, the rapidity with which the inflammation disappeared would have seemed almost a piece of magic.
* * *
A third case is that of a woman who carried a bad heart for years. About a year ago she experienced an acute attack accompanied by pain, nausea, and bloating caused by gas. Her daughter telephoned to a practitioner of spiritual healing and explained the trouble to her. The reply was that an immediate treatment would be given. In ten minutes the trouble was gone, and there has been no serious recurrence since.
The more one considers such convictions and the sort of people who hold them, the more impressive becomes the old saying attributed301 to Artemus Ward and indicating that our troubles arise not so much from ignorance as from knowing so much that is not so. Hundreds of other examples like those mentioned are available to demonstrate that many persons of high ability and superior education sincerely cherish beliefs which seem to have little more real support from fact or reason than the ordinary textbook delusion. Such beliefs are held as persistently by respected persons and influential groups, despite evidence to the contrary, as by psychotic patients who are segregated in hospitals.
The Mask of Sanity Page 2